i have been in a CME frenzy recently. i don't have any problems getting continued education working at an academic facility....in fact, i think i have about a third of my hours for the next two year period and it just started! sometimes you feel like studying and reading...and sometimes you don't. sometimes it is the topic and occasionally it is just the frame of mind you are in. i have been reading a TON of books in the last couple months, but i hadn't been reading much medicine. i think i was a little burned out on the topic of cancer (which is what i usually hear or read).
just in the last couple days i just have enjoyed reading anything medical. today i was reading some of the journal of clinical oncology online to catch up on the "latest and greatest" there is to offer with colon, pancreatic cancer, etc. i usually peruse the other organ systems as well.
honestly, the sections i enjoy most are the palliative care articles (i.e. how to make people as comfortable as possible either during treatment or after treatment is not an option) and the section called "Art of Oncology". what this boils down to is that i'm not as mathmatically oriented as i thought i was...statistics are fine, but i can't think about them every day. sometimes it just matters what the person thinks and feels about treatment and life and less about what the numbers and clinical trials say. [clarification: we need clinical trials to guide our therapies but don't want the intangibles of treatment to be overlooked].
so, i stumbled on this article which i am going to copy in its entirety. it might be a little too detailed for some, but it does give a glimpse of what is involved in coming up with a plan for just one person. i hope this is how i am with patients. i know i am not this way in every instance, but it is definitely what i strive for. this is why i work in oncology.
Every Cancer Patient Needs Radiation Therapy!!Benjamin W. Corn
From the Institute of Radiotherapy, Tel Aviv Medical Center, Tel Aviv, Israel.The request for consultation is submitted. A 72-year-old retired engineer with renal cell carcinoma has back pain due to bone metastases in the thoracic vertebral bodies (T6-T10). The pain is refractory to opioid analgesics. The referring physician underscores that the patient received a course of spinal irradiation to this region 3 years ago and derived significant benefit. Our service is consulted to determine whether reirradiation to the same area is possible. The question has intriguing radiobiological consequences, and I send the resident physician to see the patient; she returns 3 hours later. She is beaming with pride. She has acquired a sense of scholarship about the patient and the disease. As she walkes into my office, there is a newfound swagger about her, and she is clearly anxious to disclose her findings to me. After providing a summary of the disease history, including a learned dissertation about the tartgeted therapies, which he did not respond to during the interval since diagnosis, she concludes with a piece of information that the other physicians have overlooked. It turns out that the patient has
already been reirradiated to the thoracic spine as part of an experimental protocol at a neighboring hospital. Although the chart did not initially contain a summary of that second course of radiotherapy, she has since obtained the treatment records and portal images from the hospital down the road. Retreating is not an option since he has received the maximum allowable dose. As much as I consider myself a "treater", even I have my limits. I conclude that absent an institutional review board-approved protocol for re-reirradiation, I must decline to subject this older gentleman to the beam. In view of the dose-fractionation schedules employed and the volumes of tissue exposed, we resolve that we cannot introduce any more radiotherapy, even with an armamentarium at our disposal that includes the latest in therapies (eg, intensity-modulated radiation therapy, stereotactic body radiation therapy, and so on).
The time has come for me to meet the patient. Together, the resident and I cross the bridge that leads to the ward where the patient waits. This wing of the medical center has not yet been renovated, and it feels that we have stepped back into the hospital that time has forgotten. Just before we enter the room, the resident unleashes a volley of existential questions directed at me, her senior (supposedly more knownledgeable) mentor. "How can we help him maintain hope? How can despair be averted? Have we nothing to offer?!"
I am introduced as the attending physician. I, too, am anxious when I realize that there is no obvious oncologic intervention for me to recommend. Just as I am about to come up with some meaningless jargon, the resident again draws down on her instincts as healer.
She sits on the edge of the bed and engages the patient in conversation. By now, she has learned enough about his social history to carry out sophisticated small talk. Neither he nor she appears to notic me. In some way she has deftly managed to convey that we can not treat him. He is unphased and much more interested in keeping the dialogue alive. The patient then endeavors to bring me into the conversation. In addition to a very high intelligence quotient, he is endowed with large quantities of emotional intelligence. "Do you see what she has done?" he queries me as if
I am the juniot trainee in need of didactic teaching. I am not given the opportunity to respond. Instead, he continues. "This budding cancer specialist, the exquisite young lady is gifted. She has managed to convey to me that there is nothing that can be actively pursued. But she has made it clear, and I believe her, that she will not abandon me. She has smothered me with her presence. She
radiates love."
It is the latter statement that lingers within me. Suddenly, I realize that we can avail ourselves of another type of radiation therapy--one that has nothing to do with linear accelerators or heavy particles, but everything to do with being sincere. It is a radiation therapy that is not an outgrowth of an Ivy League education, but one that is borne of intense empathy. It is a form of therapy that can be practiced by senior faculty members and first-year trainees, nurses and hopsital orderlies, and caregivers and everybody's neighbors.
In writing this essay, I began with a title that was deliberately provocative and even bombastic. In concluding this piece, I believe that the title is actually understated. It is not just every
cancer patient who needs this type of radiation therapy, it is every
patient. In fact, it is every human being.
Journal of Clinical Oncology, Vol 27, No 13 (May 1), 2009: pp. 2288-2289
